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ﺑﻴﺎﻧﺎﺕ ﺍﻟﺤﺎﺩﺙ
2 ﻋﺪﺩ ﺍﻟﻤﺮﻛﺒﺎﺕ ﺍﻟﻤﺸﺘﺮﻛﺔ ﺑﺎﻟﺤﺎﺩﺙ ﻋﺪﻡ ﺗﺮﻙ ﻣﺴﺎﻓﺔ ﻛﺎﻓﻴﺔ ﺳﺒﺐ ﺍﻟﺤﺎﺩﺙ ﺍﻟﺮﺋﻴﺴﻰ 29/08/2023 ﺗﺎﺭﻳﺦ ﺍﻟﺤﺎﺩﺙ
No. of Vehicles Involved Primary Cause Accident Date
ﻣﻌﺒﺪ -ﺟﺎﻑ ﺣﺎﻟﺔ ﺳﻄﺢ ﺍﻟﻄﺮﻳﻖ ﻻ ﻳﻮﺟﺪ ﺳﺒﺐ ﺍﻟﺤﺎﺩﺙ ﺍﻟﺜﺎﻧﻮﻱ 19:03 ﻭﻗﺖ ﺍﻟﺤﺎﺩﺙ
Road Condition Secondary Cause Accident Time
ﻧﻬﺎﺭﺍ ﺣﺎﻟﺔ ﺍﻟﺮﺅﻳﺔ ﺻﺪﻡ -ﻣﺮﻛﺒﺔ ﻧﻮﻉ ﺍﻟﺤﺎﺩﺙ ﺷﺎﺭﻉ 316 ﺍﻟﻤﻮﻗﻊ
Visibility Type of Accident Location
The Affected Party ﺍﻟﻄﺮﻑ ﺍﻟﻤﺘﻀﺮﺭ )( / The Liable Party ﺍﻟﻄﺮﻑ ﺍﻟﻤﺘﺴﺒﺐ ﺑﺎﻟﺤﺎﺩﺙ /
ﻣﺤﻤﺪ ﻧﻌﻴﻢ ﻣﺨﺘﺎﺭ ﺍﺣﻤﺪ Driver Nameﻛﺮﻳﺸﻨﺎ ﻛﻮﻣﺎﺭ ﺟﺎﻳﺴﻮﺍﻝ ﺍﺳﻢ ﺍﻟﺴﺎﺋﻖ
558909651 566558266 Mobile Number ﺭﻗﻢ ﺍﻟﻬﺎﺗﻒ
11/04/1986 15/07/1994 Age ﺍﻟﻌﻤﺮ
ﺫﻛﺮ Genderﺫﻛﺮ ﺍﻟﺠﻨﺲ
ﺑﺎﻛﺴﺘﺎﻥ Nationalityﺍﻟﻬﻨﺪ ﺍﻟﺠﻨﺴﻴﺔ
2152019 4153759 License No ﺭﻗﻢ ﺍﻟﺮﺧﺼﺔ
ﺩﺑﻲ License Issue Placeﺩﺑﻲ ﻣﺼﺪﺭ ﺍﻟﺮﺧﺼﺔ
15/08/2025 05/08/2028 License Expiry Date ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺮﺧﺼﺔ
- 9007638630 Liable Party Fine No ﺭﻗﻢ ﻣﺨﺎﻟﻔﺔ ﺍﻟﻤﺘﺴﺒﺐ
- Jordan Insurance Companyﺍﻻﺭﺩﻧﻴﺔ ﻟﻠﺘﺄﻣﻴﻦ - Dubai National Insurance Insurance Companyﺩﺑﻰ ﺍﻟﻮﻃﻨﻴﻪ ﻟﻠﺘﺎﻣﻴﻦ ﺷﺮﻛﺔ ﺍﻟﺘﺄﻣﻴﻦ
DB-C-31838 2160779 Policy No ﺭﻗﻢ ﺍﻟﺒﻮﻟﻴﺼﺔ
05/07/2024 26/02/2024 Ins. Expiry Date ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺒﻮﻟﻴﺼﺔ
75048ﺃﻡ ﺍﻟﻘﻴﻮﻳﻦ ﺧﺼﻮﺻﻲ A 68738 Plate Detailsﺃﺑﻮﻇﺒﻲ ﺧﺼﻮﺻﻲ 18 ﺑﻴﺎﻧﺎﺕ ﺍﻟﻠﻮﺣﺔ
ﺭﺍﺟﺎ ﺷﺎﻩ ﺣﻤﻴﺪ ﺯﺍﻛﺮ ﺣﺴﻴﻦ ﺯﺍﻛﺮ ﺣﺴﻴﻦ Owner Nameﺩﻭﻟﺮ ﺍﻟﺸﺮﻕ ﺍﻻﻭﺳﻂ ﻟﺘﺎﺟﻴﺮ ﺍﻟﺴﻴﺎﺭﺍﺕ -ﺷﺮﻛﻪ ﺍﻟﺸﺨﺺ ﺍﻟﻮﺍﺣﺪ ﺫ ﻡ ﻡ ﺍﺳﻢ ﺍﻟﻤﺎﻟﻚ
- SUZUKI/ERTIGA - - WHITEﺍﺑﻴﺾ 2023 - - TOYOTA/YARIS - - WHITE Make-Model-Color-Yearﺍﺑﻴﺾ 2022 - ﺍﻟﻨﻮﻉ-ﺍﻟﻄﺮﺍﺯ-ﺍﻟﻠﻮﻥ-ﺍﻟﺴﻨﺔ
05/06/2024 26/01/2024 Reg. Expiry Date ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﻤﻠﻜﻴﺔ
ﺑﺴﻴﻄﺔ -ﺍﺿﺮﺍﺭ ﻓﻲ ﺍﻟﻤﻘﺪﻣﺔ ﻭﺍﻟﻤﻮﺧﺮﺓ ﻟﻠﻤﺮﻛﺒﻪ Level of Damagesﺑﺴﻴﻄﺔ -ﺍﺿﺮﺍﺭ ﻓﻲ ﺍﻟﻤﻘﺪﻣﺔ ﻟﻠﻤﺮﻛﺒﻪ ﺩﺭﺟﺔ ﺍﻷﺿﺮﺍﺭ
ﻣﻼﺣﻈﺎﺕ ﻫﺎﻣﺔ:
ﺗﻘﺪﻡ ﺗﻘﺎﺭﻳﺮ ﺗﻜﺎﻟﻴﻒ ﺗﺼﻠﻴﺢ ﻣﺮﻛﺒﺎﺕ ﺍﻷﻃﺮﺍﻑ ﺍﻟﻤﺘﻀﺮﺭﺓ ﺇﻟﻰ ﺷﺮﻛﺔ ﺍﻟﺘﺄﻣﻴﻦ .ﻭ ﻓﻴﻲ ﺣﺎﻟﺔ ﻋﺪﻡ ﻗﺒﻮﻟﻬﺎ ﻣﻦ ﻗﺒﻞ ﺍﻟﺸﺮﻛﺔ ﺍﻟﻤﺨﺘﺼﺔ ﺗﺤﺎﻝ ﺇﻟﻰ ﺍﻟﺸﺮﻃﺔ ﻻﻋﺘﻤﺎﺩﻫﺎ. .1
ﻻ ﻣﺎﻧﻊ ﻣﻦ ﺗﺼﻠﻴﺢ ﺍﻷﺿﺮﺍﺭ ﺍﻟﺘﻲ ﺣﺼﻠﺖ ﻓﻲ ﺍﻟﻤﺮﻛﺒﺎﺕ ﺍﻟﻤﺸﺘﺮﻛﺔ ﻓﻲ ﺍﻟﺤﺎﺩﺙ ﺍﻟﻤﺪﻭﻧﺔ ﺗﻔﺎﺻﻴﻠﻪ ﺃﻋﻼﻩ. .2
ﻟﻐﺎﻳﺔ ﺍﻹﻋﺘﺮﺍﺽ ﻋﻠﻰ ﺍﻟﺘﻘﺮﻳﺮﻳﺮﺟﻰ ﺯﻳﺎﺭﺓ ﺍﻟﻤﺮﻛﺰ ﺍﻟﻤﻌﻨﻲ ﺧﻼﻝ 24ﺳﺎﻋﺔ. .3
ﻧﺴﺨﺔ ﺍﻟﻤﺘﻀﺮﺭ ﺍﻟﺮﻗﻢ ﺍﻟﺴﺮﻱ Security Code / ﺭﻗﻢ ﺍﻟﺘﻘﺮﻳﺮ Report Number /
Affected Party Copy 21020 223010456754
ﻣﺮﻛﺰ ﺷﺮﻃﻪ ﺍﻟﻤﻮﺍﻧﺊ ﺍﻟﻤﺮﻛﺰ 29/08/2023 ﺗﺎﺭﻳﺦ ﺍﻟﺘﻘﺮﻳﺮ Report Date /
ﺑﻴﺎﻧﺎﺕ ﺍﻟﺤﺎﺩﺙ
2 ﻋﺪﺩ ﺍﻟﻤﺮﻛﺒﺎﺕ ﺍﻟﻤﺸﺘﺮﻛﺔ ﺑﺎﻟﺤﺎﺩﺙ ﻋﺪﻡ ﺗﺮﻙ ﻣﺴﺎﻓﺔ ﻛﺎﻓﻴﺔ ﺳﺒﺐ ﺍﻟﺤﺎﺩﺙ ﺍﻟﺮﺋﻴﺴﻰ 29/08/2023 ﺗﺎﺭﻳﺦ ﺍﻟﺤﺎﺩﺙ
No. of Vehicles Involved Primary Cause Accident Date
ﻣﻌﺒﺪ -ﺟﺎﻑ ﺣﺎﻟﺔ ﺳﻄﺢ ﺍﻟﻄﺮﻳﻖ ﻻ ﻳﻮﺟﺪ ﺳﺒﺐ ﺍﻟﺤﺎﺩﺙ ﺍﻟﺜﺎﻧﻮﻱ 19:03 ﻭﻗﺖ ﺍﻟﺤﺎﺩﺙ
Road Condition Secondary Cause Accident Time
ﻧﻬﺎﺭﺍ ﺣﺎﻟﺔ ﺍﻟﺮﺅﻳﺔ ﺻﺪﻡ -ﻣﺮﻛﺒﺔ ﻧﻮﻉ ﺍﻟﺤﺎﺩﺙ ﺷﺎﺭﻉ 316 ﺍﻟﻤﻮﻗﻊ
Visibility Type of Accident Location
The Affected Party ﺍﻟﻄﺮﻑ ﺍﻟﻤﺘﻀﺮﺭ )( / The Liable Party ﺍﻟﻄﺮﻑ ﺍﻟﻤﺘﺴﺒﺐ ﺑﺎﻟﺤﺎﺩﺙ /
ﺳﻮﻧﻴﻞ ﻛﻮﻣﺎﺭ ﻫﺎﺭﻳﺮﺍﻡ Driver Nameﻛﺮﻳﺸﻨﺎ ﻛﻮﻣﺎﺭ ﺟﺎﻳﺴﻮﺍﻝ ﺍﺳﻢ ﺍﻟﺴﺎﺋﻖ
971504765510 566558266 Mobile Number ﺭﻗﻢ ﺍﻟﻬﺎﺗﻒ
20/05/1979 15/07/1994 Age ﺍﻟﻌﻤﺮ
ﺫﻛﺮ Genderﺫﻛﺮ ﺍﻟﺠﻨﺲ
ﺍﻟﻬﻨﺪ Nationalityﺍﻟﻬﻨﺪ ﺍﻟﺠﻨﺴﻴﺔ
791494 4153759 License No ﺭﻗﻢ ﺍﻟﺮﺧﺼﺔ
ﺩﺑﻲ License Issue Placeﺩﺑﻲ ﻣﺼﺪﺭ ﺍﻟﺮﺧﺼﺔ
12/07/2024 05/08/2028 License Expiry Date ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺮﺧﺼﺔ
- 9007638630 Liable Party Fine No ﺭﻗﻢ ﻣﺨﺎﻟﻔﺔ ﺍﻟﻤﺘﺴﺒﺐ
ﺷﺮﻛﺔ ﻋﻤﺎﻥ ﻟﻠﺘﺎﻣﻴﻦ )ﺵ.ﻡ.ﻉ( - Dubai National Insurance Insurance Companyﺩﺑﻰ ﺍﻟﻮﻃﻨﻴﻪ ﻟﻠﺘﺎﻣﻴﻦ ﺷﺮﻛﺔ ﺍﻟﺘﺄﻣﻴﻦ
0102010102029698 2160779 Policy No ﺭﻗﻢ ﺍﻟﺒﻮﻟﻴﺼﺔ
13/12/2023 26/02/2024 Ins. Expiry Date ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﺒﻮﻟﻴﺼﺔ
70149ﺩﺑﻲ ﺧﺼﻮﺻﻲ F 68738 Plate Detailsﺃﺑﻮﻇﺒﻲ ﺧﺼﻮﺻﻲ 18 ﺑﻴﺎﻧﺎﺕ ﺍﻟﻠﻮﺣﺔ
ﺳﻮﻧﻴﻞ ﻛﻮﻣﺎﺭ ﻫﺎﺭﻳﺮﺍﻡ Owner Nameﺩﻭﻟﺮ ﺍﻟﺸﺮﻕ ﺍﻻﻭﺳﻂ ﻟﺘﺎﺟﻴﺮ ﺍﻟﺴﻴﺎﺭﺍﺕ -ﺷﺮﻛﻪ ﺍﻟﺸﺨﺺ ﺍﻟﻮﺍﺣﺪ ﺫ ﻡ ﻡ ﺍﺳﻢ ﺍﻟﻤﺎﻟﻚ
- -HYUNDAI - TUCSONﻓﻀﻲ 2009 - - TOYOTA/YARIS - - WHITE Make-Model-Color-Yearﺍﺑﻴﺾ 2022 - ﺍﻟﻨﻮﻉ-ﺍﻟﻄﺮﺍﺯ-ﺍﻟﻠﻮﻥ-ﺍﻟﺴﻨﺔ
13/11/2023 26/01/2024 Reg. Expiry Date ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎﺀ ﺍﻟﻤﻠﻜﻴﺔ
ﺑﺴﻴﻄﺔ -ﺍﺿﺮﺍﺭ ﻓﻲ ﺍﻟﻤﻮﺧﺮﺓ ﻟﻠﻤﺮﻛﺒﻪ Level of Damagesﺑﺴﻴﻄﺔ -ﺍﺿﺮﺍﺭ ﻓﻲ ﺍﻟﻤﻘﺪﻣﺔ ﻟﻠﻤﺮﻛﺒﻪ ﺩﺭﺟﺔ ﺍﻷﺿﺮﺍﺭ
ﻣﻼﺣﻈﺎﺕ ﻫﺎﻣﺔ:
ﺗﻘﺪﻡ ﺗﻘﺎﺭﻳﺮ ﺗﻜﺎﻟﻴﻒ ﺗﺼﻠﻴﺢ ﻣﺮﻛﺒﺎﺕ ﺍﻷﻃﺮﺍﻑ ﺍﻟﻤﺘﻀﺮﺭﺓ ﺇﻟﻰ ﺷﺮﻛﺔ ﺍﻟﺘﺄﻣﻴﻦ .ﻭ ﻓﻴﻲ ﺣﺎﻟﺔ ﻋﺪﻡ ﻗﺒﻮﻟﻬﺎ ﻣﻦ ﻗﺒﻞ ﺍﻟﺸﺮﻛﺔ ﺍﻟﻤﺨﺘﺼﺔ ﺗﺤﺎﻝ ﺇﻟﻰ ﺍﻟﺸﺮﻃﺔ ﻻﻋﺘﻤﺎﺩﻫﺎ. .1
ﻻ ﻣﺎﻧﻊ ﻣﻦ ﺗﺼﻠﻴﺢ ﺍﻷﺿﺮﺍﺭ ﺍﻟﺘﻲ ﺣﺼﻠﺖ ﻓﻲ ﺍﻟﻤﺮﻛﺒﺎﺕ ﺍﻟﻤﺸﺘﺮﻛﺔ ﻓﻲ ﺍﻟﺤﺎﺩﺙ ﺍﻟﻤﺪﻭﻧﺔ ﺗﻔﺎﺻﻴﻠﻪ ﺃﻋﻼﻩ. .2
ﻟﻐﺎﻳﺔ ﺍﻹﻋﺘﺮﺍﺽ ﻋﻠﻰ ﺍﻟﺘﻘﺮﻳﺮﻳﺮﺟﻰ ﺯﻳﺎﺭﺓ ﺍﻟﻤﺮﻛﺰ ﺍﻟﻤﻌﻨﻲ ﺧﻼﻝ 24ﺳﺎﻋﺔ. .3